Ending preventable maternal deaths within the next generation is within our reach. On April 12, the Lancet reported in a special issue, that virtually ending preventable deaths from pneumonia and diarrhoea of children under five, which currently cause one third of the burden of under-five mortality, could be a reality by 2025. These are ambitious global goals. Yet they are achievable if real progress happens not only in countries where the burden is currently greatest, but also by reaching the most vulnerable population in every country, giving equal access to life-saving interventions to all.
The Millennium Development Goals (MDGs) 4 and 5 represent a concerted effort to address global maternal and child mortality — yet they look at achieving specific targets (1) by the end of 2015. The goals of eliminating preventable deaths of women and children must be targeted beyond 2015. While the MDGs have made a difference, with unprecedented reductions in the rates of maternal and child health globally, we are far from reaching the goals and there is a significant gap in the current progress towards MDGs 4 and 5 between and within countries. The Eastern Mediterranean Region of the WHO(2) is a young region with 73 million children aged 5 years or less (12.2 percent of the population) and 171 million women of childbearing age (28.6 percent of the population). Both, women and children underfive are highly vulnerable groups. When looking at reaching MDGs 4 and 5, the Eastern Mediterranean Region is one of the regions where the gap is greatest.
That is not to say that there has been no progress in the Region. On the contrary, the under-five mortality rate has decreased by 32 percent, from 100 deaths per 1000 live births in 1990 to 68 per 1000 live births in 2010. Yet, more than 900,000 children under five years of age die in the region every year, with 83 percent of the total deaths occurring in six countries (Afghanistan, Pakistan, Somalia, Yemen, South Sudan and Sudan). The annual reduction of maternal mortality rates between 1990 and 2010, has been 2.6 percent and almost 40,000 women of childbearing age die every year as a result of pregnancy-related complications. These deaths occur particularly among the pregnant adolescents, with 94 percent of the burden shared by seven countries (Afghanistan, Iraq, Morocco, Pakistan, Somalia, Sudan and Yemen).
In response to this challenge, the countries of the Region, convened by WHO, UNICEF and UNFPA in collaboration with other partners met to launch a regional initiative aimed at accelerating progress. The regional initiative firstly focused on the 10 countries in the region which count amongst the highest burden countries in maternal and child health: Afghanistan, Djibouti, Egypt, Iraq, Morocco, Pakistan Somalia, South Sudan, Sudan and Yemen.
The regional initiative kicked-off at a first high-level meeting entitled “Saving the lives of mothers and children: rising to the challenge,” in Dubai, United Arab Emirates, on 29 and 30 January 2013. Under the patronage of Sheikh Mohammed Bin Rashid Al Maktoun, Vice-President and Prime Minister of the UAE, and Princess Haya Bin Al Hussein, UN Messenger of Peace and Chairperson of Dubai Healthcare City Authority, an unprecedented commitment was signaled by the strong regional engagement, with 150 participants including ten Ministers of Health, senior officials and leading figures from 22 Member States.
As the region looks to improve the lives of the most vulnerable, the leaders have begun to reinforce the region’s commitment to women’s and children’s health, grounded in equitable principles, and to discuss policies for accelerated action towards the achievement of MDGs 4 & 5 in the region. The EMR has success stories of how implementing effective RMNCH interventions and delivery strategies have led to successful reduction of maternal and child death rates. For example, Egypt has achieved universal coverage with the integrated management of childhood illnesses and high coverage of maternal health interventions. The Islamic Republic of Iran has scaled up primary care for maternal, newborn and child health, building on the success of community health workers.
Yet in some countries serious challenges remain, limiting the implementation and effectiveness of policies. Examples of these challenges include insufficient political support and Midwife Huma Awar Sumadi. “I became a midwife because I knew too many women who were dying during pregnancy,” Huma says. “It is important for people living in such remote communities to be seen by qualified health workers to improve their health.” leadership, restricted and unequal access to care, weak health systems, low workforce capacities and inadequate ability to monitor progress and track results and resources. The challenge now facing the high-burden countries of the Region is how to achieve universal coverage of effective interventions while optimizing investments and enhancing accountability to improve the health of women and children.
As a region the challenges impacting health, nutrition and development outcomes are quite unique. This is compounded by the fact that a large number of countries, especially the four countries with the highest burden of maternal and child mortality, are experiencing crises and significant population displacement at different times. The critical need to address the inequities that exist within and among countries, and the additional challenges posed in many countries by humanitarian crises are well understood, and these challenges can only be overcome through a true regional partnership.
To achieve the goals set by MDGs in the region, the countries with highest burden have identified the “best buys” for maternal and child health — i.e. those health interventions which are most effective and affordable, and will make the biggest difference. These include: family planning, pregnancy care and skilled attendance at childbirth and immediately after; vaccines; treatment for the main childhood diseases (notably pneumonia and diarrhoea); improving nutrition including breastfeeding; and access to clean water and sanitation. Scaling up the packages is estimated to save up to 20,000 lives of pregnant women and one million lives of under-five children by 2015 in the ten priority countries in the region. The cost associated with this scaly up range from an additional US$ 1.6 per capita in 2013 increasing to US$ 3.8 by 2015, for a maximum of US$4 billion for 2013-2015.
Although ambitious, the scenarios are realistic. However, they will only become a reality through the transformation of the strong willingness and commitment from all countries to move forward with the work through a truly regional partnership.
The adoption of the “Dubai Declaration,” signaled this strong commitment. Countries committed to develop and execute plans for maternal and child health; take measurable steps to strengthen their health systems; and mobilize domestic and international resources to establish sustainable financing mechanisms.
The Governments, however, are not solely responsible for this progress. Other partners need to work together with countries, to improve coordination and promote cooperation within the region. The Declaration places great importance on addressing social and environmental determinants of maternal and child health, such as poverty, gender, water and sanitation, nutrition, and education, and the need to monitor progress. For this, countries committed to establishing a regional commission on women’s and children’s health.
The initiative in EMRO is driven by the regional solidarity between countries. It builds on and contributes to the national commitments already made by countries towards the goals of the UN SG Global Strategy for Women’s and Children’s health and Every Woman Every Child, as well as the specific initiatives under its umbrella (such as the UN Commission on Life Saving Commodities for Women and Children, A Promise Renewed to Child Survival and Family Planning 2020). The progress achieved in the region will be monitored, following the accountability framework put in place by the Commission on Information and Accountability linked to the UN Global Strategy.
In the declaration, countries commit to hold themselves accountable for the collective progress towards their goals. On behalf of all mothers, adolescents and children in the region, they recommit to making every woman and every child count, giving every woman the best opportunity for safe delivery so that every child has the best possible start in life.
The principles and commitment in the Dubai declaration align and support specific national and international efforts to accelerate progress towards meeting the MDGs. They also support an ambitious vision as we look beyond the end of 2015, and a feasible goal of virtually ending all preventable deaths of women and children. With the progress achieved in the past few years, this is now a goal, which can be achieved within the next generation.
The accountability process, which will follow, will demonstrate how the commitment translates into impact in the lives of every woman and every child in the region.
1. MDG4: to reduce by two-thirds between 1990 and 2015 the under-five mortality rate. MDG 5: to reduce by three quarters the maternal mortality ratio and improve maternal health in the same period.
2. EMRO comprises 23 countries geographically distributed through the Middle East and North Africa.